Written by Tsung-Mei Cheng.
Non-communicable diseases (NCDs) have become a major component of China’s disease burden in recent years. As of 2012 NCDs accounted for 70% of the total disease burden and 70% of total national health expenditure in China. The problem poses a major challenge not only to China’s health care system, but also to future Chinese economic growth.
The factors that drive the growth of NCDs in China are many-fold, but several stand out. First, in China, as elsewhere, the ageing of the population naturally brings with it growth in NCDs. At this time the fraction of China’s population aged 65 and older – 9.7% in 2013 — is still much lower than those in older industrial societies (including Japan). The comparable fractions in European countries range between 16.45% in Eastern European countries and 18.75% in rich Western European countries; and in the rest of the industrialized world as follows: 18% in the U.K., 14% in the U.S., 16% in Canada, and 15% in Australia in 2014. In Japan, the oldest country in the world, 26% percent of the Japanese population was already aged 65 years and older in 2013.
The demographic problem for China is less the current fraction of the population over age 65 but the rapidity in the growth of ageing. While the doubling of the proportion of people aged 65 and over from 7% to 14% took 46 years in the U.K., 68 years in the U.S., and 116 years in France, it took all but 26 years in China. Driven by both a low birth rate and increases in life expectancy, that trend of rapid ageing is likely to continue in China.
A second major driver of NCDs in China is changes in lifestyle, brought about by rapid economic growth and rapid urbanization. Unhealthy diets have increased overweight and obesity in China. According to the 2015 government report (Chinese) on nutrition and chronic disease in China, 30% of Chinese aged 18 and older are overweight, and close to 12% are obese. According to the same report, a total of 28% of those aged 15 years and older are smokers, of whom 53% are men. All told there are 300 million smokers in China.
Finally, China’s miraculous economic growth during the past three and a half decades has come at a high price: environmental degradation, which is one of the most severe cases the world has seen in modern times. Air and water pollution are known to be major risk factors driving NCDs such as cancer and cardiovascular and pulmonary disease.
The costs imposed on China by NCDs are of two sorts. First, there are the direct costs of treating NCDs. As noted above, in 2010 total spending on NCD accounted for 70% of China’s total national health spending, which in turn represents 3.22% of China’s total GDP in 2010.
Second, and sometimes overlooked, there are the macro-economic costs in the form of lost potential gross domestic product (GDP) from ill health in the population. One estimate, for example, using a macroeconomic model, suggests that for the period 2012-2030 that lost output in China will total US$ 19 trillion for just four major NCDs: cardiovascular disease, cancer, respiratory disease (COPD), and diabetes. This estimate, however, is derived from NCD mortality data alone. Inclusion of NCD-related morbidity data would drive the estimate far higher. By comparison, in 2014, total GDP of China was US$ 10.4 trillion.
To address the challenge of NCDs in China, the government will have to use a multi-pronged approach. For one, it must take steps to reduce the risk factors that drive the growth of NCDs in China. China’s embrace of the WHO’s health-in-all-policies initiative (HiAP) is a sign that the Chinese government is actually trying to do so. Part of this strategy must be to address quite seriously the environmental decay that has accompanied China’s economic growth. To the extent that NCDs are driven by lifestyle, China must also embark upon a major educational campaign to teach the Chinese people how better to manage their own health. An encouraging sign is that the government now has in the field some major initiatives to do just that. Examples include the ‘National Campaign on Health Lifestyle for All,’ National Demonstration Sites for Integrated NCD Prevention and Control, the “Four Reductions” Program (a national program to reduce intake of salt, sugar, oil, and alcohol), etc.
China should also continue to invest in its health-care sector to reduce current barriers to timely and needed health care for NCDs. Although ever since China embarked on its major health reform in 2009 the government has invested vast sums in its health system, that system is still plagued by severe capacity constraints, especially in its health workforce. Now that China’s economy is no longer growing at the former double-digit rates and the government seeks to restructure its economy away from reliance on exports and real-estate construction and toward more domestic consumption, expanding the health-workforce can serve as a major source of employment growth in China, as health sectors have been throughout the developed world in recent decades.
Finally, the Chinese government should continue to deepen its health-insurance coverage reform. In 2000, just 15% of Chinese citizens had any form of health insurance coverage. The major health reforms the Chinese government embarked on drastically changed that. Today more than 95% of the Chinese population has health insurance coverage. However, out-of-pocket (OOP) spending by households, although much reduced from years earlier, remains high by the standards of OECD countries. According to an internal government report OOP as a percent of China’s total national health spending for 2010 was 35%, but that for NCDs was considerably higher at 47% of China’s total spending on NCDs in 2010. This high out-of-pocket spending constitutes a significant financial barrier to needed health care for many Chinese, especially low-income households and the poor.
NCDs are a challenge to every country in the OECD. So far, however, these countries have been able to cope with the problem because their health systems have had the capacity to do so. China is not in this fortunate position as yet, but the Chinese government recognizes both the magnitude and the urgency of the problem and is taking steps to address it.